HIPAA Content Form

Student's FULL Name(*)

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Phone Number(*)

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Email Address(*)

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Student's Social Security Number(*)

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Date of Birth(*)

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Student Health Services reserves the right to release health information based upon a decision by your medical provider here for medical emergency situations and in general for continuity of care. We will use your health information as needed to maintain our internal operations. We will release your information to anyone else that you may elect in writing to receive it.

Other than the above mentioned release, your personal healthcare information will NOT be released to others, including your parent(s), unless listed below.

Indicated by entering below, I give permission to provide information to the following: